Gateway to the West Days Parade 2011Nebraska Department of Roads
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Saftecial Event Fo"'hermit
OR
T Nebraska
Department of Roads
Applicant/Permittee:
City of Blair
Beginning DatefTime: Ending Date/Time:
June 11, 2011 -1:00 P.M. June 11, 2011 - 3:00 P.M.
Event Name:
Gateway to the West Days Parade
This permit is issued subject to all terms and conditions set forth in the Special Event and State Closure
Requirements /Instructions and the Application for Special Event Permit, copies of which are attached
hereto and incorporated herein by this reference.
Additional terms and conditions specific to this event that shall apply:
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NDOR )7�strict Engineer or Designee Signature
Attachments:
1. Permittee Application for Special Event Permit
2. Special Event State Highway Closure Requirements /Instructions
Distribution: Permittee, District Engineer, State Patrol
Date
Revised 2010
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Event Name:
Type of Event:
City celebration
X Total Closure ❑ Partial Closure
Nebraska Department of Roads
0
Applicat for Spec Event Perm
Gateway to the West Days Parade
City, Village, or County Requesting Permit:
Address:
Contact Person for Traffic Control:
I (we)
City of Blair
218 South 16 Street
Allen Schoemaker
City of Blair
for a special event permit upon the right -of -way of
Highway No.
June 11, 2011
and Milepost 449 on
30/75
Date(s)
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pi,
Nebraska
Department of Roads
Event Dates and Times:
June 11, 2011 from 1:00 pm to
3:00 pm
Estimated Number of Participants:
500
Phone No(s.):
402 - 426 -4191
hereby make application
between Milepost 448
between 1:00 PM and 3:00 PM.
-------- - - - - - -•
- - - - -- Time(s) - - - - -- Time(s)
Event Description: (ATTACH EVENT MAP /SCHEDULE, ETC.)
Closure of Highway 30/75 from 14 Street west to 18 Street for a parade that is a part of the
City's annual celebration
In the event a Special Event Permit is granted, I (we) the undersigned, having full authority to bind the entity
on whose behalf this Special Event Permit is sought, agree to strictly conform to the Special Event Permit,
subject to all terms, conditions, agreements, and provisions contained therein, including all attachments thereto,
and shall fully defend, hold harmless and indemnify the State of Nebraska, Department of Roads, and its officers,
agents, employees, and members from any and all suits or actions which may result from• any activity by the
permittee, its officers, subcontractors, agents, employees, guests, and /or participants in any manner relating to or
arising out of the identified special event for which this permit is sought/granted.
Allen Schoemaker 218 South 16 Street
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----------- -- - ------- - --- - - - -
-- - -- -- - - ------------------------------------
Address
Name and Title (please print)
Blair, Nebraska 68008
--------------------------------
---------------------------------------------------------------------------------------------------------
------- ----------------------------------------- g------- - - - - -- ----- - - - - -- City, State, and Zip Code
Signature
3/23/11 402 - 426 -4191
------------
--------------------------------------------------------
•------------------------------------------------------------------------------------------------------- - - - - -- Telephone No.
Date (minimum of 30 days prior to event)
AGREEMENT OF CITY, VILLAGE, COUNTY, POLITICAL SUBDIVISION OR OTHER GOVERNMENTAL ENTITY, IF THE
CLOSURE RESTRICTS OR REQUIRES THE USE OF ITS ROAD, STREET, HIGHWAY OR PROPERTY:
Approved by, if applicable:
---- ------------------------------ Phone No.
Name, Entity, and Title (please print)
Approved by, if applicable:
---------------------------------------- (p---lease ------- - - print) - - -- Phone No.
Name, Entity, and Title
-------------- -- - - -- e -------- - - - - --
------------- - - - - -- Date
_________________________________________. Date Signature
Signature
BLAIR, NE. 68008
402 -426 - 4707
4SURED 'C1.ty of Blair
218 S 16th Street
Blair, NE 68008
INSURERS AFFORDING COVERAGE NAIC#
INSURER A: EMC TnsJurance companies
INSURER B.
INSURER, C•
INSURER D'
.IYy4.14.. ti-
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT, TERM OR CONDITION OF ANY
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
MAY PERTAIN, THE INSURANCE AFFORDED BY THE
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE REDUCED BY PAID CLAIMS.
INSR
LTR
D'L
NERD
TYPE OF INSURANCE
- POLICY NUMBER
PATE MMlDD1YY E
RA E(MMIDQ�ON
LIMITS
1 0
GENERAL LIABILITY
EACH OCCURRENCE
S
$ 100 ,00 0
i COMMERCIAL GENERAL LIABILITY
PREMISES Ea Sr urenca
5 1 000
CLAIMSMADE FR OCCUR
MED EXP (Anyone parson)
E
PERSONAL &ADV INJURY
S 1 000 000
A,
x
'
OD71456
11- 01 -11
GENERAL AGGREGATE
5 2 0 0 0 Q O O
PRODUCTS - COMP !DP AGG
S 2 0 0O 0 O 0
NX EN'L AGGREGATE LIMIT APPLIES PER'
POLICY JR LOC
AUTOM08I41<LIABILITY
COMBINED SINGLE LIMIT
(Ea accident}
$ 1,000,0
X ANYAUTO
ALLOWNEDAUTOS
BODILYINJURY
(Per Person)
$
A,
SCHEDULED AUTOS
HIRED AUTOS
0 E71456
11- -01 -10
11-01-11
BODILY INJURY
•$
(Peraccident)
NON- OWNEDAUTOS
PROPERTY DAMAGE
$
(Peraccident)
AUTO ONLY -EA ACCIDENT
$
GARAGE LIABILITY
EA ACC
$
ANYAUTO
OTHERTHAN
AUTO ONLY AGO
$
EACH OCCURRENCE
S 4 0 0 Q, 0 Q 0
EXCESS/UMBRELLA LIABILITY
AGGREGATE
$ 4 000 040
X OCCUR CLAIMSMAOE
OL771456
11 -01 -10
11 -01 -11
$
$
A
S DEDUCTIBLE
$
RETENTION $
TORYLIMITS ER�
WORKERSCOMPENSATIONAND
EMPLOYERTLIABILITY
0H71456
11- 01-10
1 1-01-11
E.L EACH ACCIDENT
S 500,000
E,L DISEASE - EA EMPLOYE4
$ 5
ANY PROPRIETORIPARTNEWEXECUTIVE
A
OFFICER/MEMBER EXCLUDED?
I(yes describeunder
SPE6 AL PROVISIONS below
E.L DISEASE - POLICY LIMIT
$ 500 ,000
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES J EXCLUSIONS , DDEDBYENDORSEMENT !SPECIALPROVISIONS
State of .Nebraska Department of Roads listed as additional insured on a primary
and non - contributory basis. City of Blair agrees to waive its rights of
recovery against the .State. Waiver of Subrogation in favor of the State
Nebraska is included.
State of Nebraska
Nebraska Department of Roads
4455 South 108th St.
Omaha, NE 68145
AC(ORD 25(2001108)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFItrATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,. ITS AGENTS OR
REPRESENTATIVES.
ORATION 1 s88